Prevalence and Effects of Client Violence on Social Workers:

Implications for Keeping Social Workers Safe

National Association of Social WorkersFlorida Conference

June 11, 2010

Pam Criss, PhD, LCSWSoutheastern University

Purposes of TrainingTo understand what personal and organizational

factors may be related to client violence toward social workers

To discover how social workers are affected when they have encountered client violence

To discover how much safety training is occurring with social workers, where training occurs and whether the training has a beneficial effect.

To discuss implications for social workers and their agencies, with particular emphasis on safety training

U.S. Statistics for Social Services and Health CareBureau of Labor(BLS) statistics 2000 - 48%

of all non-fatal injuries from occupational assaults and violent acts occurred in health care and social services (OSHA, 2004).

BLS also reports that the violent assault injury rate for health care and social services is seven and a half times the rate for the overall private sector.

Reasons for increased risk to mental health professionals• Increased use of hospitals for the care of acutely

disturbed individuals

• Increasing numbers of chronically mentally ill people being released from hospitals without follow up care

• Long waits for agency services

• Low staffing rates

• Low staffing rates may lead to working in isolation in agencies (OSHA, 2004)

Reasons for increased violence towards mental health professionals• Solo work at remote locations

• Prevalence of handguns

• Increased membership in gangs

• Increased presence of drugs and alcohol (OSHA, 2004)

Reasons for increased violence towards social workers (Weinger, 2001)

Cuts in services/provisions

Increasing violence in society

Social control role for social workers – social workers are often in a position where they must set limits for clients and/or to report when clients have failed to meet court ordered requirements

Reasons for increasing violence towards social workers•Negative image of social workers –

representatives of unwanted authority (Aren’t you the ones who take children out of their homes?)

NASW Center for Workforce StudiesAlmost 5000 licensed social workers in

the U.S. responded to the survey (135 from Florida; 4 BSW social workers replied)

47% had some concern about their personal safety

The report concludes that “ a profession cannot successfully retain its workforce when issues of personal safety go unaddressed” (p. 35).

Prevalence of Client Violence against Social WorkersMore than 20 studies on client violence

toward social workers in the U.S. within the past 30 years.

National prevalence rates for social workers’ exposure to violence indicate that between 65% and 86% of social workers have encountered client violence at some time during their career (Beaver, 1999; Ringstad, 1995).

Practice exercise: Recording the numbers of client violence incidents that have occurred to youPlease complete the form regarding

numbers of client violence incidents that you have experienced directly or indirectly in the past year.

Client Violence Rates for Social Work Students•Prevalence rates for social work students’

exposure to violence in their practicum have ranged from 21% to 54% (Knight, 1999; Mama, 2001).

Client Violence towards Social Work Students (Criss, 2009)

•Participants▫Random sample of 1500 social work

students from NASW national membership, with equal numbers of BSW and MSW students

▫Oversampled students of ethnic/racial minority groups – 1/3 of BSW and MSW students

▫45.25% response rate (N = 667)▫595 students met inclusion criteria

(completed or currently in field placement)

Prevalence of Direct Client Violence towards Social Work Students41.7% (n = 248) - Experienced some type of client violence

Rate of Client Violence by Type of Violence (N= 589)

% n

Verbal abuse 37.5 223

Threat of physical harm

14.1 84

Threat of lawsuit 9.4 56

Property damage

7.2 43

Physical assault 3.2 21

Total Number of Incidents of Client Violence Towards Social Work Students

Sum of incidents

% of total incidents

Verbal abuse

759 68.75%

Threat of physical harm

161 14.58%

Threat of lawsuit

79 7.15%

Property damage

77 6.97%

Physical Assault

28 2.53%

Total incidents

1104 99.98%

Vicarious exposure to client violence•In study of 273 child protection social

workers, Horwitz(2006) found that vicarious exposures to traumatic workplace events were more highly associated with trauma effects than were direct events.

Prevalence of Indirect Exposure to Client Violence towards Social Work Students60.2% (n = 361) Witnessed and/or heard about some type of client violence

Type of Client Violence

% n

Verbal abuse 54.1 322

Threat of physical harm

36.8 219

Physical assault 23.4 139

Threat of lawsuit 23.4 139

Property damage 20.5 122

Total Number of Indirect Incidents of Client Violence Experienced by Social Work Students (n = 361)

Sum of indirect incidents

% of total incidents

Verbal abuse

1852 51.40

Threat of physical harm

751 20.70

Physical assault

388 10.46

Property damage

324 8.91

Threat of lawsuit

309 8.52

Total indirect incidents

3603 99.9

Failure to report client violenceWhen social workers are harmed by

clients, they may often fail to report the incidents.

One study indicated that 8% of violent incidents were reported only verbally and only 29% were recorded appropriately (Norris, 1990).

Reasons for failing to report violenceConcern about how the worker will be

perceived by co-workers and supervisorsFear of criticism, rather than support Fear that management might see them as

unable to cope, being inadequate, or as unprofessional (Brown, Bute, and Ford, 1986; Norris, 1990; Spencer & Munch, 2003).

“ I needed to be told that I hadn’t failed.” (Littlechild, 1997, p. 236)

Reasons for failure to report violencePerception that violent incidents are part

of the job

Tendency to feel that social workers should be able to take care of themselves, so they may report only the most severe incidents.

Social workers do not enter the profession thinking that they will become victims of the very people they hope to help.

(Star, 1984)

Reasons for failure to report violenceAfraid that if they report the violence,

their relationship with their client will deteriorate or that their client will face prosecution (Rowett, 1986; Star, 1984).

Both assaulted and non assaulted social workers may picture assaulted social workers as poorly functioning social workers. The non assaulted workers may see the assaulted workers as being more provocative, incompetent, authoritarian, and inexperienced (Macdonald & Sirotech, 2001; Rowett,1986).

Reasons for failure to report violence•Norris points out that, like child abuse,

victim disclosure must occur in order for the problem to be understood and reasonably addressed. He states that “the key to knowing how to protect social workers from the most unpredictable of attacks, without imposing protective measures that destroy the helpful aspects of social work, lies in overcoming the problem of under-reporting” (p.131).

Which gender of social workers experiences more client violence?

Prevalence of Client Violence- Gender• Several studies indicate that males are at higher

risk of encountering client violence than females (McLean, 2000; Newhill, 2006; Jayarante, Croxton, & Mattison, 2004; Ringstad, 2005; Beaver, 1999).

• Two contradictory findings: Males had more physical assault, threats of physical harm, and threat of property damage, but females experienced more verbal abuse (Song,2005)

• Male social workers in Israel didn’t experience more physical threats and assaults, though American males did. (Guterman, Jayarante,& Bargel, 1996)

Male social work students experienced significantly more client violence than female social work students (Criss, 2009).

Males (n = 68, 11.4%), Females (n = 525, 88.5%)

Types of Client Violence

Gender Mean t-value p

Physical assault Female .04 -1.36 .179Male .12

Threat of physical harm

Female .21 -3.24 .002***

Male .69Verbal abuse Female 1.05 -2.20 .031*

Male 3.09Threat of lawsuit Female .13 -1.01 .314

Male .19Property damage Female .12 -1.21 .230

Male .22Total client violence Female 1.59 -2.45 .017*

Male 4.32

Do older social workers or younger social workers experience more client violence?

Prevalence of Client Violence-Age• Younger workers in agency settings have been

found to be at greater risk of physical threat, threat of lawsuit, verbal abuse and sexual harassment (Jayarante et al., 2004; Jayarante, 2005, Ringstad, 2005)

• Younger workers also significantly more like to report knowing co-workers who had experienced physical threats

• Younger student social workers more likely to view social work as a dangerous profession and expressed some discomfort working in inner city (Knight, 1996)

In national study, younger social work students did not experience more client violence, though those who were aged 25-30 experienced significantly more threats of lawsuit (Criss, 2009).

Age Categories Physical Assault

Threat of Physical Harm

Verbal Abuse

Threat of lawsuit

Property Damage

Total Client Violence

M SD M SD M SD M SD M SD M SD

Under age 25(n = 145)

.69 .35 .23 .65 .84 1.84 .08 .31 .06 .29 1.27 2.60

Age 25-30(n = 162)

.03 .26 .39 1.05 1.57 4.53 .22 .64 .13 .52 2.35 5.55

Over age 30(n = 285)

.05 .25 .23 .75 1.34 4.11 .11 .45 .16 .67 1.89 4.90

F = .710 F = 2.26 F = 1.48 F = 4.01 F = 1.61 F = 2.03

p = .491 p = .106 p = .229 p = .019* p = .201 p = .132

Do more experienced workers or less experienced workers have more exposure to client violence?

Prevalence of Client Violence- Job experience• Early client violence study showed that workers

with 11 or more years of experience were assaulted or threatened at a ratio of 1:4 compared with workers with less than 11 years experience (Bernstein, 1981)

• Less experienced workers have been found in other studies to have more exposure to client violence (Privatera, 2005; Beaver, 1999)

• Less experienced social worker in U.S. had more violent incidents, though not true with less experienced workers in Israel (Guterman et al., 1996)

Prevalence of Client Violence- Job experience

•One conflicting finding- “Professionally seasoned MSW’s” experienced more client violence that “less experienced student clinicians” (Tully, Kropf, and Price, 1993)

NASW Workforce Study (2006)

Student with no experience or less than 2 years experience had less direct exposure to client violence than students who had 3-5 years experience. Those with 3-5 years experience had significantly more verbal abuse and total client violence (Criss, 2009)

Experience Categories

Physical Assault

Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

M SD M SD M SD M SD M SD M SD

No experience(n = 292)

.03 .22 .19 .71 .88 1.87 .09 .30 .10 .47 1.29 2.66

1-2 years’experience(n = 89)

.04 .21 .33 .94 1.27 3.19 .17 .63 .18 .70 2.00 3.97

3-5 years’experience(n = 82)

.10 .46 .37 .94 2.07 6.21 .15 .61 .17 .58 2.85 7.24

6-10 years’Experience(n = 66)

.03 .17 .37 1.06 1.21 2.26 .20 .59 .09 .52 1.86 3.58

F = 1.38 F = 1.65 F = 3.01 F = 1.53 F = .75 F = 3.45

p = .247 p = .177 p = .030* p = .205 p = .520 p = .016*

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Do social workers of minority ethnic groups or races experience more client violence than white social workers ?

Prevalence of Client Violence- Ethnicity/Race• There has been little research on how social

workers of ethnic minorities in the U.S. are affected by client violence.

• Some evidence that social workers of ethnic minorities in the U.K. are disproportionately affected by client violence (Butt, 2000, as cited in Brockman, 2002)

• One study found that non-White social workers worried more about future exposure to workplace violence, though they experienced less than White participants (Budd, Arvey, & Lawless, 1996)

Prevalence of Client Violence- Ethnicity/Race• Another study showed that African American social

workers were significantly less likely to have fear of all types of client violence (Jayarante, Croxton, and Mattison, 2004)

• Yet another study found that ethnic minorities were significantly more likely than White social workers to view the community around a school as dangerous (Astor, 1998)

• One epidemiological study of several U.S. national workplace violence studies showed that African American and Hispanic workers had higher frequencies/rates of workplace violence (Kraus, 1996)

Native American social work students were significantly more likely to experience verbal abuse and total client violence, whereas students of mixed racial/ethnic heritage were more likely to experience threat of lawsuit and property damage.(Criss, 2009)

Practice Setting Physical Assault

Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

M SD M SD M SD M SD M SD M SD

Latino/Hispanic(n = 25)

.00 .00 .20 .65 .80 1.32 .20 .58 .04 .20 1.24 2.06

NativeAmerican(n = 13)

.15 .55 .46 .77 6.61 14.80 .08 .28 .38 1.12 7.92 18.01

White(n = 425)

.04 .28 .27 .83 1.15 3.30 .12 .46 .13 .54 1.80 4.42

Asian(n = 5)

.00 .00 .60 1.34 1.20 2.16 .20 .48 .20 .45 3.00 3.74

Black(n = 98)

.04 .24 .25 .86 1.25 2.80 .09 .35 .04 .31 1.70 3.43

Mixed Heritage(n = 19)

.16 .50 .37 .68 1.57 2.46 .58 1.12 .47 1.26 2.52 3.30

F = 1.14 F = .38 F = 5.43 F = 3.54 F = 2.59 F = 4.26 p = .339 p = .858 p = .000*** p = .004*** p = .025* p = .001***

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Do BSWs or MSWs experience more client violence?

Prevalence of Client Violence- Social Work DegreeOnly two studies have reported on client

violence rates with BSW social workers vs. MSW social workers.

Both found that social workers with a BSW experienced more client violence (Beaver, 1999; Privitera, Weisman, Cerulli, Tu, & Groman, 2005)

MSW students experienced more of every type of violence, except physical assault. They were significantly more likely to experience threat of physical harm, verbal abuse, and total client violence.MSW (n = 340, 57.1%), BSW (n = 248, 42.2%) (Criss, 2009)

Types of Client Violence Gender Mean t-value p

Physical assault MSW .03 1.42 .156

BSW .07

Threat of physical harm MSW .35 -2.77 .004***

BSW .17

Verbal abuse MSW 1.52 -1.94 .053*

BSW .96

Threat of lawsuit MSW .16 -1.77 .077

BSW .09

Property damage MSW .13 .22 .826

BSW .14

Total client violence MSW 2.24 -1.96 .031*

BSW 1.50

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Does client violence occur more often in an office, at a home visit or in some other place?

Prevalence of Client Violence-Place of ViolenceA study of probation officers, about half of whom

were social workers, found that they were more likely to be verbally threatened and physically intimidated in the office (Rapp-Paglicci, 2004)

One study of child welfare workers found that different types of violence happened in different places:Threats- Client’s homeProperty damage- OfficeActual attacks- Wide array of places (Newhill & Wexler, 1997)

Prevalence of Client Violence-Place of ViolenceTwo student social work studies found

that incidents of violence were more likely to take place in an agency (Mama, 2001; Tully et al., 1993)

A small study of child welfare workers (n=31), 61.3% of the social workers had been threatened while on a home visit, whereas 94% had heard of a coworker being involved in a client violence situation (Castellanos, 1998)

Another study with a small sample size of 15 home visiting social workers found that 93% had experienced client violence and none of them felt completely safe (Vergara, 2006)

A student study found that 48% of MSW students were concerned about their personal safety at least sometimes when making home visits. Of those, 30.1% had actually encountered verbal threats during a home visit and 45% were physically threatened during a home visit (Schwarzmueller, 1998)

Client violence during home visits

Every type of client violence except physical assault was experienced by social work students more often in an office setting.

Practicum Exposure Rate to Client Violence per Place of Violence (N = 274)

Place of Violence

Physical Assault

Threatened Physical Harm

Verbal Abuse

Threatened Lawsuit

Property Damage

Total Client Violence

% n % n % n % n % n % n

Home visit

11.8 2 24.7 20 26.9 57 15.7 8 8.1 3 23.4 148

Office 41.2 7 54.3 44 51.4 109 58.8 30 70.3 26 54.4 64

Other 47.1 8 21.0 17 21.7 46 25.5 13 21.6 8 22.6 62

Of social work students who made home visits, those who made 11 or more home visits experienced more of every type of violence and significantly more threats of lawsuit.Number of

Home Visits Made

Physical Assault

Threat of Physical Harm

Verbal Abuse

Threat of lawsuit

Property Damage

Total Client Violence

M SD M SD M SD M SD M SD M SD

1-5 home visits(n = 84)

.02 .15 .15 .53 .85 1.73 .06 .24 .13 .65 1.21 2.27

6-10 home visits(n = 55)

.07 .33 .16 .60 .73 1.46 .07 .36 .07 .42 1.10 2.31

11 or more home visits(n = 177)

.08 .38 .40 1.09 1.35 2.94 .25 .70 .16 .66 2.24 4.17

F = .86 F = 2.71 F = 2.00 F = 4.57 F = .46 F = 3.71p = .422 p = .068 p = .137 p = .011** p = .632 p = .027*

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

What time of day is client violence more likely to occur to a social worker?

Time of day of client violenceStudent study found that almost 40% of students

were concerned for their personal safety during evening hours (Knight, 1999)

Another student study found that 33% experienced physical threats during evening hours (Schwarzmueller, 1998)

Analysis of seven national (non social work) studies indicated that occurrence of homicide and nonfatal assault is more frequent in the afternoon and evening hours than late morning or early afternoon hours (Kraus, 1996)

Social work students experienced client violence much more often during daytime hours.

Practicum Exposure Rate to Client Violence per Time of Day

Time of Violence

Physical Assault

Threat of Physical Harm

Verbal Abuse

Threat of lawsuit

Property Damage

Total Client Violence

% n % n % n % n % n % n

Daytime 76.5 13 71.8 56 71.6 151 82.0 42 71.4 25 69.69 184

Evening 23.5 5 24.4 19 26.5 56 13.7 7 25.7 9 26.13 69

Early morning

0 0 3.8 3 1.9 4 3.9 2 2.9 1 4.16 11

Those social work students who worked 51-75% of their practicum hours during the evenings were significantly more likely to experience physical assault than those who worked up to 50% of their hours during the evening or those who worked almost all of their hours during the evening (Criss, 2009)

% of Evening Hours Worked

Physical Assault

Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

M SD M SD M SD M SD M SD M SD

No evening hours(n = 197)

.04 .23 .24 .80 1.38 5.40 .12 .48 .12 .59 1.89 6.24

1-25% evening hours(n = 253)

.05 .28 .23 .74 1.08 2.38 .16 .54 .14 .59 1.68 3.29

26-50% evening hours(n = 65)

.02 .12 .32 .83 1.07 2.03 .09 .34 .09 .38 1.60 2.77

51-75% evening hours(n = 43)

.16 .57 .53 1.32 2.14 4.45 .09 .36 .20 .80 3.02 5.86

76-100% evening hours(n = 30)

.00 .00 .23 .68 1.47 3.08 .20 .55 .20 .80 2.10 3.84

F = 2.34 F = 1.35 F = 81 F = .54 F = .30 F = .83p = .054* p = .250 p = .520 p = .704 p = .881 p = .501

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

In what practice settings is client violence most likely to occur to a social worker?

Practice settings noted to have higher prevalence of client violence

Child protection settings (Jayarante et al., 2004; Newhill, 1996; Schultz, 1987; Snow, 1994)

National survey of child welfare workers in 10 states found that over 70% had been victims of violence or threats of violence (AFCME, 2007)

Qualitative study in Ontario of 20 child welfare workers- All said that they had been kicked, spit upon, and hit by clients using weapons of various sorts.

95% verbally abused 60% said it was a daily occurrence

Seattle Times, by Jonathan MartinSocial worker, Edith Vance, 52 yrs. old, Washington

Father slain after machete attack on social workerA machete-wielding father was fatally shot yesterday after he attacked a veteran Child Protective Services (CPS) worker in the worst-known case of on-the-job violence at the state child-welfare agency.

A machete-wielding father was fatally shot yesterday after he attacked a veteran Child Protective Services (CPS) worker in the worst-known case of on-the-job violence at the state child-welfare agency.

The CPS worker, accompanied by a co-worker and a Ferry County sheriff's deputy, was investigating a complaint that three children were living in a home near Curlew without running water or electricity when she was attacked by the children's father, State Patrol trooper Jim Hays said.

Bryan S. Russell, 35, pummeled one of the social workers with a machete and a 2-by-4 as she lay on the ground before the sheriff's deputy shot and killed him, Hays said.

The worker, whose name was not released, suffered cuts, a broken arm and wrist and a possible skull fracture. She was admitted to Deaconess Medical Center in Spokane for a CAT scan.

Ms. Vance’s advocacy to the Washington state legislature

by Rachel LeCort, Associated Press, Vancouver, WA 3/25/05OLYMPIA A state social worker who was attacked by a machete- wielding

father during a child welfare check made her first public appearance Thursday, testifying in support of a bill intended to prevent future assaults.

Still sporting bandages that cover a splint on her broken right wrist, 52-year-old Edith Vance was not eager to talk about the details of the day that Bryan S. Russell beat her with a machete last month. Russell, 35, was fatally shot by a Ferry County sheriff's deputy who had accompanied Vance and another welfare worker on the visit.

Instead, Vance said she wanted to focus on the needs of workers like her, who face potential conflict every time they knock on a door, sometimes in rural areas with sketchy cell phone service. Vance has worked in child services for 22 years, of which 14 have been in Washington with the state Department of Social & Health Services.

"Wherever we need to go, there is danger present and something needs to be done to address those dangers," she told lawmakers on the Senate Human Services & Corrections Committee.

The bill, sponsored by Rep. Ruth Kagi, D-Lake Forest Park, passed the House on an unanimous vote earlier this month. It would create a work group to develop policies and consistent protocols on welfare workers' safety.

Practice settings noted to have higher prevalence of client violence

Criminal justice settings (Newhill, 2006; Beaver, 1999; Ringstad, 2005)

4 of 5 social workers in criminal justice settings have concerns about their safety (NASW, 2004)

Criminal justice workers may have more encounters with physical violence

Practice settings noted to have higher prevalence of client violenceInstitutional mental health (Jayarante et al., 1995; Jayarante

et al., 2004; Ringstad, 2005; Privitera et al. 2005)

82% of social workers working in psychiatric hospitals reported concerns about personal safety on the job (NASW, 2004)

(Florida State Hospital, Chattahoochee)

In a study of injuries to staff in a large state psychiatric hospital , 71% of the injuries to staff were head injuries (Carmel & Hunter, 1993)

Practice settings noted to have higher prevalence of client violence

School social work (Jayarante et al., 1995; Jayarante et al., 2004; Mattison, 2004; Ringstad, 2005)

School social workers may fear for their safety, especially if they are at inner city schools (Astor et al., 1998)

One study found that school social workers experienced the highest amount of assaults

National study of violence towards school social workers (Astor, Behre, Fravil, Wallace, 1997; Astor, Behre, Wallace, Fravil, 1998)

576 school social workers

More than 70% reported that potentially life threatening events occurred in their schools in the past year

Yet, only 20.5% said that violence was a big or very big problem in their school(s)

Study of school social workers (cont.)44% said that they feared for their safety

one or more times in the past year because of worries about school violence

35% physically assaulted or physically threatened within the past year

Of those: 77% identified assailant as student49% identified assailant as a parent

Practice settings noted to have higher prevalence of client violence

Any residential setting (Brockman, 2002; Leadbetter, 2003; Ringstad, 2005)

Children’s residential group care may be dangerous

Students in alcohol/substance abuse, mental health/psychiatric, and developmental disabilities settings experienced significantly more client violence. Those in community organization settings experienced the least client violence.Practice Setting Physical

AssaultThreat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

% n % n % n % n % n % nMedical/Health

2.8 2 9.9 7 39.4 28 11.3 8 1.4 1 43.7 31

Alcohol/Substance abuse

7.1 3 14.3 6 50.0 21 16.7 7 14.3 6 52.5 22

Developmental disabilities

13.3 2 20.0 3 46.7 7 0 0 6.7 1 53.3 8

Corrections/Criminal Justice

2.6 1 13.2 5 36.8 14 10.5 4 7.9 3 42.1 16

Community Organization

0 0 5.3 2 18.4 7 5.3 2 5.3 2 20.5 8

Child & Family/ChildProtection

2.9 3 9.6 10 30.8 32 14.4 15 5.8 6 38.5 40

Family services 2.0 1 15.7 8 39.2 20 9.8 5 5.9 3 37.3 19Schools 4.3 2 19.6 9 37.0 17 6.5 3 8.7 4 40.4 19Services to the Aging

7.3 3 14.6 6 34.1 14 7.3 3 2.4 1 34.1 14

Mental health/Psychiatric

3.0 3 23.0 23 47.0 47 9.0 9 14.0 14 54.5 15

X2 = 9.67 X2 = 13.60 X2 = 15.45 X2 = 12.47 X2 = 15.62 X2 = 19.17 p = .470 p = .192 p = .117 p = .254 p = .111 p = .038*

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Social work student- client violence study

Threats of lawsuit were significantly higher in alcohol/substance abuse settings than every other practice setting.

F (10/574) = 1.88, p = .046, η2 = .03

Predicting Occurrence of Client Violence

Model Summary for Predictors of Occurrence of Overall Client Violence

Coefficient for Final Model of Occurrence of Overall Client Violence

Step Factors R R2 R2adj ∆ R2 Fchg p df1 df2

1 Male .173 .030 .028 .030 15.66 .000 1 507

2 Mental health setting .208 .043 .039 .013 6.98 .008 1 506

3 11 or more home visits .231 .053 .048 .010 5.48 .020 1 505

4 Alcohol/substance abuse setting

.251 .063 .056 .010 5.14 .024 1 504

Factor B β t p Bivariate r

Partial r

Male .201 .125 2.84 .005 .151 .126

Mental health setting .135 .108 2.43 .015 .109 .108

11 or more home visits .115 .109 2.48 .014 .098 .110

Alcohol/substance abuse setting

.206 .106 3.37 .018 .085 .105

Predictors of Physical Assault towards Social Work Students:

▫having more field agency training, particularly in self defense topics

▫working in a developmental disability setting

•Other factors associated with physical assault:▫being aged 25-30 ▫working increased (51-75%) evening hours

Predictors of Threat of Physical Harm towards Social Work Students

▫being male▫working in a mental health practice setting

•Other factors associated with increased threats of physical harm:▫being of mixed ethnic/racial heritage▫being an MSW student▫having more field agency training

Predictors of Verbal Abuse towards Social Work Students

▫being male▫interning in a mental health setting▫making 11 or more home visits,▫ interning in an alcohol/substance abuse

setting.•Other factors associated with verbal

abuse of students:▫ Native American▫ MSW student▫ having 3-5 years’ experience▫ receiving more training in field seminar, the field

agency and sources other than the social work program

Predictors of Threat of Lawsuit towards Social Work Students

▫being 25-30 years old▫being of mixed ethnic heritage▫making more home visits▫interning in an alcohol/substance abuse

setting •Additional factors associated with threat

of lawsuit:▫having more field agency training

Predictors of Property Damage towards Social Work Students

▫being male▫working in a mental health/psychiatric

setting •Other factors associated with property

damage:▫Being of mixed racial heritage▫having more field agency training

Effects of Client Violence

Effects of Client Violence

•When social workers are the victims of client violence, they can experience the acute effects of trauma that include becoming timid, withdrawn, frightened, nervous, and angry (Guy & Brady, 1998; Horwitz,

2006; Norris, 1990; Snow, 1994) .

From Brady, C. Surviving the incident

Possible reactions following assault

Immediately following assault

In the days following assault (24-72 hours)

In the long term

Physical painShakingCryingFearShockDisbeliefConfusionEmbarrassmentAngerFeeling “energized”Feeling “ready to work”

FearAnger, resentmentDenial of effectsFeeling of lossGuilt, shame, humiliationPoor concentrationLack of confidenceAnxiety in similar situationsSleep difficultiesDepressionAttempts to make sense of what happened

Lack of confidenceSituation specific anxietyFeeling “burned out”DepressionPost-traumatic stress disorder

Initial Reactions (I was )“shocked, physically shaken,

emotionally assaulted. Jumpy and emotionally labile…” (Littlechild, 2005, p. 73)

Sense of control is lostAdrenaline surge has depleted the bodyMay be exhausted and need to rest (Weinger,

2001)

Often takes about 12 hours before employees process what has happened and are ready to talk (Ceniceros, 1999)

Longer term effects of client violence PTSD- re-experiencing the trauma, avoidance,

numbing of responsiveness, increased arousal (75% of victimized child welfare workers in

one study met criteria) (Snow, 1994)

Negative effects on health (longitudinal study indicated that even 2 years after an incident, social workers had significantly higher scores on General Health Questionnaire) (Balloch, Pahl, & McLean, 1998)

Worry about litigation/malpractice, if they had self protective responses (Guy & Brady, 1998)

Longer term effects of client violenceMore caution in practice

Less ability to confront clients (Norris, 1990)

“ I watch every word I say or write, body language, everything. This probably results in a stilted lack of communication.”

“General reluctance to visit. Difficulty being positive with my client. My anxiety and anger prevent me from being positive with the family.” (Littlechild, 2005, p. 73)

Long term effects of client violenceTendency to “retreat” to administrative positions

Reluctance to visit a client alone

Refusal to work certain shifts alone (Norris, 1990)

Long term effects of client violenceSelf blame

Feelings of IncompetenceFailureGuilt Shame

Sense of vulnerability

Anger toward clients (Mostly unspoken)

(Weinger, 2001)

Long term effects of client violenceMay affect the worker’s private life

“My family was concerned about the nature of my work and risks involved.”

“Reduced visits to town with husband and teenager children- not wanting to put them at risk… Watching back mirror when driving home, stopping en route to ensure not being followed.”

“My husband gets angry that I have to put up with such behavior and suffer the effects in my private life.”

(Littlechild, 2005, p. 73)

Long term effects of client violence towards students Uncomfortable engaging in all practice

activities

Tendency to plan to be in private practice

(Knight, 1999)

Measuring Fear of Future Violence

Fear of future violence- Fear that a client violence incident will occur in the future

• Used a modified version of Fear of Future Violent Events at Work Scale (Rogers & Kelloway, 1997).

• Measured by noting level of agreement that

the student had fear that each of 5 client violence events would occur in the next year.

Direct experience of client violence significantly affected fear of future client violence.

(Direct Experience)

Physical Assault

Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

r p r p r p r p r p r pFear of Physical Assault

.08 .042* -- -- -- -- -- -- -- -- -- --

Fear of Threat of Harm

-- -- .22 .000*** -- -- -- -- -- -- -- --

Fear of Verbal Abuse

-- -- -- -- .13 .000*** -- -- -- -- -- --

Fear of Threat of Lawsuit

-- -- -- -- -- -- .19 .000*** -- -- -- --

Fear of Property Damage

-- -- -- -- -- -- -- -- .09 .040* -- --

Fear of Any Type of Client Violence

.02 .564 .18 .000*** .13 .002*** .15 .000*** .08 .043*. .15 .000***

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Indirect experience of client violence significantly affected fear of future client violence (Even more so than direct experience of client violence)

(Direct Experience)

Physical Assault

Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage Total Client Violence

r p r p r p r p r p r pFear of Physical Assault

.17 .000*** -- -- -- -- -- -- -- -- -- --

Fear of Threat of Harm

-- -- .23 .000*** -- -- -- -- -- -- -- --

Fear of Verbal Abuse

-- -- -- -- .21 .000*** -- -- -- -- -- --

Fear of Threat of Lawsuit

-- -- -- -- -- -- .29 .000*** -- -- -- --

Fear of Property Damage

-- -- -- -- -- -- -- -- .14 .001*** -- --

Fear of Any Type of Client Violence

.17 .000*** .21 .000*** .21 .000*** .27 .000*** .15 .000*** .27 .000***

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Effects of violence- Career turnoverExperiences of client violence may be

related to social workers’ decisions to leave the profession (Lyons, Lavalle, & Grimwood, 1995).

Only study to date to look at possible reasons for turnover in the profession of social work

• 791 social workers from 21 schools in England

• Verbal and physical abuse by clients; 92% had been verbally abused, 32% had experienced physical violence

Some of those who had left cited violence as a reason for leaving.

Effects of violence- Career turnover•In one study, 19% of those attacked

reported not wanting to return to work, being reluctant to practice with certain types of clients or wanting to change jobs

“It has reinforced my belief that the profession does not take the threat of violence seriously….. It adds to other reasons to leave social work.” (Newhill & Wexler, 1997)

NASW Center for Workforce Studies (2004)• 5% of the social work workforce planned

to leave the profession of social work• The workers in this group were more

likely :▫ to be between the ages of 26 to 34▫to have a BSW as their highest degree▫to be in their first four years of practice

• They were significantly more likely to report that they faced personal safety issues.

Measuring Occupational Commitment• Occupational commitment is “a person’s belief in

and acceptance of values of his or her chosen occupation or line of work and willingness to maintain membership in that occupation” (Vandenberg and Scarpello, 1994)

• Three types of occupational commitment: a. Affective- The participant’s attitudes and

feelings toward the occupation and his/her identification with the profession (Staying because they want to do so)

(Meyer, Allen & Smith, 1993)

Types of Occupational Commitment b. Normative- Remaining with the

occupation because the participant feels that they ought to do so.

c. Continuance- Staying in the occupation because the participant needs to do so. It involves tangible items such as salary, time investment and job security.

(Meyer, Allen & Smith, 1993)

Relationship between client violence and occupational commitment

(Direct Experience)

Physical Assault Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

r p r p r p r p r p r p

Affective Commitment

.04 .359 .03 .488 .01 .910 .00 .998 .02 .679 .02 .682

Normative Commitment

.11 .011** .05 .271 .01 .733 .02 .572 .05 .192 .03 .474

Continuance Commitment

.06 .143 .04 .384 .02 .686 -.07 .091 -.01 .776 .01 .837

Career Withdrawal Intentions

-.06 .162 .00 .839 .780 .35 .00 .944 .05 .516 .01 .858

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

There were significant positive correlations between normative and continuance commitment and all types of client violence.

There were significant negative correlations between affective commitment and experiences of physical assault and threats of physical assault.

Fear of Physical Assault

Fear ofThreat of Physical Harm

Fear of Verbal Abuse

Fear of Threat of lawsuit

Fear of Property Damage

Fear of Any Client Violence

r p r p r p r p r p r p

AC -.10 .014** -.08 .046* -.01 .820 -.04 .285 -.07 .089 -.07 .102

NC .14 .001*** .13 .002*** .18 .000*** .13 .002*** .12 .003*** .17 .000***

C C .17 .003*** .12 .004*** .17 .000*** .15 .000*** .12 .004*** .17 .000***

Note: * p ≤ .05, **p ≤ .01,*** p ≤ .004 (Significant after Bonferroni adjustment)Note: AC =Affective Commitment; NC = Normative Commitment; CC = Continuance Commitment

Safety Training

Training on Safety and ViolenceTime spent in safety training may be

limited National random study of 1000 social workers:

▫ 4% recalled receiving training BSW/MSW program▫ 3% recalled training at field internship site▫ 79% said that they needed more safety training (Newhill, 1996)

National study of school social workers: 5% recalled receiving training during their social work

education▫ 62% said that they had training from the school district▫ 70% got training at conferences▫ 59% said they needed more training on school violence (Astor et al., 1998)

Training on Safety and Violence 175 social workers:41% had training on predictors of violence2% had training on violence prevention22% had training on home visit safety

(Rey, 1996)

Training on safety for field educators who have students in the field59%- 94% of field educators/instructors report a need

for more training on client violence (Mama, 2001; Tully et al., 1993)

Only 30% of social work education programs give safety training to their field educators/instructors (Ellison, 1996)

Median time that field educators spent in safety training- 45 minutes (Ellison, 1996)

Social work student training- student perspectiveTraining at field agencies:32% - training on how to handle dangerous

situations at the field agency (Mama, 2001)

35%- agency training about predicting violence18%- training on home visit safety (Elwood & Rey, 1996)

Training in social work curriculum:Slightly over half had safety training in the social

work curriculum (Tully et al., 1993)

18%- training on predictors of violence41%- violence prevention43%- threats towards students (Elwood & Rey, 1996)

Knowledge of agency safety policies

•2 social work student studies asked about students’ knowledge of field agencies’ policies- about ½ of the students were aware of agency safety policies (Mama, 2001; Elwood & Rey, 1998)

Social work student safety training- Field director’s perspectives•61%-69% say that they offer safety

training (Faria & Kendra, 2007; Ellison, 1996; Reecer & Wertkin, 2001)

•Median length of safety training- 2 hours (Ellison, 1996)

Social work student safety training- Field director’s perspectives•Many social work field directors feel that

it the primary responsibility of the field instructor ( in the agency) to provide field training to students, but:a. they don’t know how many of the field

agencies are actually providing training orb. not all field agencies may be providing

training (Reeser & Wertkin, 2001; Faria & Kendra, 2007)

Social work student safety training- Field director’s perspectives• 12% -26% of social work education programs

have some type of safety policy

• Some say they have informal policies, though a large amount of those stated that the informal policy consisted on relying on safety training in field seminar, student orientations, and social work practice classes.

• MSW programs were significantly more likely to have safety training policies.

• Those programs in which a student had been physically assaulted were more likely to have safety policies.

(Ellison, 1996; Faria & Kendra, 2007; Reeser & Wertkin, 2001)

Safety training content in social work schools• Only one study has asked field directors

specifically about safety training content (Faria & Kendra, 2007)

• 90% (n=12) of those programs that offered safety training said that they included content on:▫Characteristics of high risk situations▫Creating safe office spaces▫High-risk practice settings▫Maintaining a confident, secure demeanor▫Verbal de-escalation of a client’s rage▫How t0 behave with an angry client▫How to dress▫How to sit when interacting with a client

Client Violence Training Content Areas by Venue (Criss, 2009)

0102030405060708090

100

Training Content Areas

Social Work Classes Field Seminar Field Agency Other Training

Percentages of Students Who Had Safety Training Content per Training Venue

Training Content Social WorkPractice Classes %

Social WorkField Seminar %

Field Agency %

Other

%

Assessing history of violence in clients 33.9 (n=202) 8.6 (n=51) 27.1 (n=161) 14.8 (n=88)

Characteristics/life experiences of people more likely to commit violent acts

42.2 (n= 251) 8.9 (n=53) 20.2 (n=120) 16.3 (n=97)

Forms of mental illness associated with violent behavior

55.5 (n= 330) 11.4 (n=68) 24.5 (n=146) 23.0 (n=137)

Characteristics of high risk situations (i.e. non-public, isolated places)

48.1 (n=286) 24.4 (n=145) 31.1 (n=185) 23.9 (n=142)

Identifying and managing feelings that can arise when working with victims and perpetrators of violence

51.1 (n=301) 20.8 (n=124) 28.6 (n=170) 18.7 (n=111)

Maintaining a confident, secure demeanor 52.8 (n=214) 26.7 (n=159) 33.3 (n=198) 22.5 (n=134)

Recognizing verbal acts of violence 41.8 (n=249) 16.1 (n=96) 27.2 (n=162) 23.5 (n=140)

Physical signs that an attack is imminent 24.9 (n=148) 12.1 (n=72) 23.0 (n=137) 21.8 (n=130)

Understanding of student’s rights (For example, the right to refuse to make a home visit)

38.0 (n=226) 33.6 (n=200) 22.9 (n=136) 8.2 (n=49)

Percentages of Students Who Had Safety Training Content per Training Venue Training Content Social Work

Practice Classes %

Social WorkField Seminar %

Field Agency

%

Other

%

Verbal de-escalation techniques( How to behave with an angry client)

44.0 (n=262) 19.5 (n=116) 31.3 (n=186) 25.2 (n=150)

Knowledge of office safety (arranging work space to maximize safety)

38.8 (n=231) 20.3 (n=121) 32.6 (n=194) 19.0 (n=113)

Where to sit when interacting with a client 58.0 (n=345) 26.6 (n=158) 32.6 (n=194) 19.0 (n= 113)

Home visit safety 35.5 (n=211) 25.2 (n=150) 29.9 (n=178) 17.3 (n= 103)

Keeping supervisor informed of one’s itinerary 35.6 (n=212) 30.1 (n=179) 49.1 (n=292) 17.6 (n= 105)

Physical techniques for self protection 14.5 (n=86) 8.7 (n=52) 17.5 (n=104) 25.9 (n= 154)

Debriefing and support after an incident (Reporting the incident)

31.3 (n=186) 19.8 (n=118) 38.7 (n=230) 19.8 (n=118)

Recording incidents of violence 27.6 (n=164) 15.3 (n=91) 37.8 (n=225) 19.3 (n= 115)

Knowledge of social work program’s safety policies

40.5 (n=241) 30.9 (n=184) 25.0 (n=149) 10.4 (n= 62)

Knowledge of field agency’s safety policies 16.5 (n=98) 15.6 (n=93) 67.3 (n=385) 6.5 (n= 6.2)

Is safety training effective?Prior to this study, only one social work

study had done a simple measure of the relationship between exposure to client violence and safety training(Elwood & Rey). No other social work studies have assessed the effectiveness of safety training.

Current study hypothesized that increased safety training would correlate with decreased incidents of client violence

Study showed that safety training and incidents were positively correlated (i.e. Increased training correlated with increased incidents of violence)

Training Venues

Physical Assault Threat of Physical Harm

Verbal Abuse Threat of lawsuit

Property Damage

Total Client Violence

r p r p r p r p r p r p

Social work classes

.02 .717 -.01 .848 .07 .098 -.01 .947 .03 .434 .06 .151

Field Seminar .02 .611 .04 .402 .10 .013* .08 .058 .07 .122 .11 .009**

Field Agency .11 .009** .14 .001*** .09 .029* .08 .044* .11 .010** .13 .002***

Other places -.01 .888 .04 .363 .08 .046* .06 .154 .10 .022* .09 .027*

Total Training .06 .179 .04 .049* .14 .001*** .09 .039* .12 .004*** .15 .000***

Note: * p ≤ .05, **p ≤ .01, *** p ≤ .004 (Significant after Bonferroni adjustment)

Why could it be that client violence was higher when social work students had more safety training?

(No, really!.. I need some helping in solving this!)

What might make safety training more effective?

Effective training consists of: Presenting knowledge about a subjectProviding a demonstrationAssuring opportunities to practice the

skills in the training setting (Fixen, Naoom, Blase, Friedman, & Wallace, 2005)

Other professions, such as nursing, have done a better job of conducting training and evaluating its effectiveness (i.e. Beech & Leather, 2003)

What might make safety training more effective?Use of:

Simulations and role play (Guy & Brady, 1998; Horejsic & Garthwait, 1994; O’Keefe & Mennan, 1998)

Dramatic re-enactment ( Guy & Brady, 1998)

Detailed discussion about cases (Guy & Brady, 1998; O’Keefe & Mennan, 1998)

Small group exercises (O’Keefe & Mennan, 1998)

What might make safety training more effective?Discussion about field experiences (O’Keefe &

Mennan, 1998)

Use of excerpts from popular dramas to illustrate causes of violence and emotions surrounding violence (Rey, 1996)

Use of actors, both live and on video, to perform client violence situations in social work situation (Leadbetter & Phillips, 1990)

From www.safetyfundamentals.com

Safety training components

I. Understand where violence comes from (Weinger, 2001):

Innate aggressionSocial learning- We learn from what we see and

experienceFrustration leads to aggressionPeople behave violently when human needs

aren’t metDisequilibrium of power- Reaction to perceived

threatViolence occurs in context ( interaction between

person’s internal dynamics, the interpersonal situation, and the environmental system)

Safety training components-II. Recognition of potentially violent clients (Newhill, 2006; Weinger, 2001)• History of violence (most powerful predictor)

• Mental illness (overall not a good predictor)Schizophrenia (especially those with

persecutory delusions; command hallucinations of violent types)

Antisocial personality disorderBorderline personality disorderMood disorderManiaPanic disorder

Safety training components- II. Recognition of potentially violent clients (Newhill, 2006; Weinger, 2001)

Mental illness- Those with violent fantasies, especially if they have engaged in activities that reinforce the fantasies.

High levels of hostility/suspicion/ agitation/ thought disorders= likely violence, regardless of disorder

Safety training components- II. Recognition of potentially violent client(Newhill, 20036 Weinger, 2001) Substance abuse Demographics

Age15-40 (peak age15-24) Male gender Military or combat experience

Situational/environmental stressors Lack of social support

Safety training components-Recognition of potentially violent clients (Newhill, 2006)

• Biological Risk Factors▫Low I.Q. ▫Neurological impairment

• Family risk factors▫History of directly experiencing child abuse▫Witnessing child abuse or domestic violence▫Excessive punishment▫Loss of parent▫Child neglect▫Hx of mental illness of parent▫Family’s attitude about violence▫Removal of family member is imminent

Practice Exercise:Recognizing risks of violenceFor each case vignette that you have been

given, discuss the following two questions:

1. What risk factors are present?2. What precautionary measures would you

take?

(Vignettes and questions are from Weinger (2001). Security risk: Preventing client violence against social workers. )

Safety training components- III. Social worker’s self awareness concerning violenceUnderstanding of how violence may affect

victims (O’Keefe & Mennan, 1998)

Learning how to cope actively with stresses

Managing feelings that can arise when working with victims and perpetrators (O’Keefe & Mennan, 1998; Rey, 1996)

Examining one’s own value system around violence (O’Keefe & Mennan, 1998)

Safety training components- III. Social worker’s self awareness concerning violenceUnderstanding how one’s own culture

impacts victim’s exposure to violence (O’Keefe & Mennan, 1998; Adamson, 2006; Ringstad, 2005)

Gaining ability to manage one’s own anger

(Reeser & Wertkin, 2001)

Understanding personal rights in the workplace ( for example, right to refuse to make a home visit or to request to be accompanied by a co-worker) (Faria & Kendra, 2007)

Safety training components- III. Social worker’s self awareness concerning violenceBe aware of bodily symptoms (Kaplan &

Wheeler, 1983)

Inform other staff members of behaviors that may upset you (Kaplan & Wheeler, 1983).

Develop comfort in asking for help or relief

when managing violent behavior in a client

Practice exercise: Self awareness concerning violent incidents•Rank the stimuli that would be likely to

evoke an emotional response in you (1= most likely to evoke a response 10= least likely to evoke a response)

•Using chart, identify what your behavioral response might be to the given circumstances

•Also list the intensity of your response to each circumstance (stimulus)

(Rage scale from Kaplan & Wheeler (1983))

Sample personal rage scalePersonal Rage

Stimulus Behavioral Response to Stimulus

Intensity of Response

Person attacking wife and kids

Murder 100%

Physically threatening gestures to me or family

Severe injury upon another

90%

Spitting at me Hit 80%

Attempts to strike me Make threatening gestures

70%

Verbal abuse towards me

Yell obscenity 60%

Fighting between 2 peers

Give direct orders to stop

50%

Continuance of annoying behavior

Leave/have person leave 40%

Continued failure to respond

Verbally tell person 30%

Misuses property Take something away 20%

Fails to respond to directions

Show that I’m upset with a frown

10%

Safety training components-IV. Understanding dynamics of violenceUnderstanding the prevalence of different

forms and types of violence (Digiulio, 2001; O’Keefe & Mennan, 1998; Rey, 1996; Reeser & Wertkin, 2001)

Understanding the use and misuse of power

Recognizing theories of violence and having ability to apply those theories (O’Keefe & Mennan, 1998; Rey, 1996)

Safety training components-IV. Understanding dynamics of violence

Cycle of ViolenceTriggering Phase

Escalation Phase

Crisis Phase

Recovery Phase

Post Crisis Phase

Safety training components-IV. Understanding dynamics of violenceUnderstanding the cycle of violence (Kaplan &

Wheeler, 1983)

Triggering phase- The client’s first move away from baseline

behavior is the beginning of this phase. Indicative a client’s discomfort. Key is to know the client, so that this phase

can be recognized. Escalation phase

Takes client to assaultive behaviors Behavioral symptoms become more

noticeable Ability to respond rationally declines Staff must take first action to curb behaviors

Safety training components-IV. Understanding dynamics of violenceUnderstanding the cycle of violence (Kaplan & Wheeler,

1983)

Crisis phaseBecomes increasingly arousedLess capable of controlling impulsesMoves into directly assaultive behaviorTop concern must be for the safety and protection of the

social workerRecovery phase

Gradual return to baseline behaviorMost errors are made hereClinicians may discount the function of the adrenaline,

which may remain active for up to 90 minutesClient should determine the pace of the interventionIt helps to reassure the client of their safety at this

point.

Safety training components-IV. Understanding dynamics of violencePost crisis depression phase

Client regresses to less than baseline behavior

Mentally and physically exhaustedRemorseful, tearful, distraught, feelings of

shameClient can begin to return to the

environment as a functional member.

Safety training components-V. Using verbal communication to diffuse violent situationsCommunicate acceptance, respect,

empathyRespond succinctly Encourage problem solvingRedirectEliminate aggressive responses ( being

non- confrontive) (Weinger, 2001)

Safety training components-V. De-escalation using verbal communicationSet appropriate limitsClients may fear losing control

Clarify limits (“It’s okay to be angry, but it is not okay to strike out at someone”)

Set firm limits

Sometimes ask or tell the client directly and repeatedly (“Put the chair down”)

Safety training components-V. De-escalation using verbal communicationStay calmSpeak:

EvenlySlowlyNeutral voice

Alter the environment Suggest that the client leave the immediate

areaLeave the room with the clientHave a snack (Weinger, 2001)

Safety training components-De-escalation using nonverbal communicationPhysical approach (Weinger, 2001)

Approach from an angleDon’t isolate yourselfDon’t turn your backMaintain appropriate distance (Give the client 5x the physical space that

you might normally give)

Practice exercise: How much physical space does a potentially violent client need?With a partner, demonstrate how much

physical space that you personally need. Then, demonstrate what 5 times that space

would look like.

Safety training components-De-escalation using nonverbal communication

Physical approachFeet apart (hips’ width)One foot extended more in front than the

otherDon’t touch!Mirror body languageDo not cross arms; rather, allow arms to

hang relaxed at your side

Safety training components-V. De-escalation using nonverbal communication (Newhill, 2006)

•Pay attention to how you are dressed▫Not too tight ▫Not too revealing or provocative▫Avoid loose or dangling earrings ▫Remove neckties▫Avoid high heeled shoes

Safety training components-V. De-escalation using nonverbal communication Eye contact

Avoid staringMake enough eye contact to convey

interest (Weinger, 2001)

Try to look at a point between his/her eyes (Newhill, 2006)

Practice exercise: Role play vignettes of interactions of potentially violent clientsWith a partner and one observer, role play

a vignette of a violent/potentially violent interchange.

First role play how not to respond to the client

Then role play how to respond to the client

Practice exercise: Role play vignettes of interactions of potentially violent clientsWhat were the cues that the “client” might

become physically aggressive?At what phase did the worker first

intervene to interfere with the assault cycle?

What did the worker do (verbally and/or non verbally) to attempt to diffuse the situation?

What was the effectiveness of these interventions?

Creating safe office space•Interview room should be in a safe

location and designated with safety in mind▫Room should be quiet▫Painted neutral colors▫Not too dim or too bright (Kaplan & Wheeler, 1987; Newhill, 1996)

Creating safe office space• Interview options, from least restrictive to most

restrictive:▫Interviewing client alone in office with door

closed▫Interviewing client alone in office with door

open▫Interviewing client alone in the office with door

open and staff members present outside the office

▫Interviewing the client with staff members present inside the office

▫Interviewing the client while the client is in physical restraints

(Tardiff, 1996)

Generally, interview clients in the least restrictive office environment that will also ensure your safety and theirs

Creating safe office space

•Consider installing alarm systems and other security devices▫Panic buttons▫Hand-held or mounted buzzers▫Cell phone▫Intercom▫Predetermined signals

(Weinger, 2001)

Creating safe office space•Evaluate all of the furnishings in the room

•Avoid having heavy objects that can be thrown and used as weapon

•Methods of calling for help should be established and routinely reviewed/ Planning for “what if” situations need to be an ongoing part of staff meetings/training

(Newhill, 2006; Weinger, 2001)

Practice exercise:Evaluating your own office setting•How risky is your own practice setting?•Evaluate the physical environment of your

office.•What modifications are needed?

(From Newhill, C. (2006). Client violence in social work practice: Prevention, intervention, and research)

Safety during home visitsKnow your clientReview case file –pay particular attention

to history of violence and risk factors for violence (Newhill, 2006)

Is there anything today that might increase the possibility of the client acting violently? (Davies, 1989)

Safety during home visitsKnow the environmentFind out what you can about potentially

dangerous neighborhoods

Find out potential dangers in a home , including finding out who will be there

Consider the time of day- Refrain from going after office hours or after dark, particularly if there are other danger signal

Safety during home visits

Know the environmentFind out if there are dangerous animals

(Scalera, 1995)

Find out about entrances and exits, if possible (Davies, 1989)

Safety during home visitsDo advanced preparationIf there is question about safety, consider

meeting the client in the office or a public place (Rey, 1996)

Consider going with another team member or supervisor, if there is a question about safety. If necessary, request escort from police officer (Newhill & Wexler, 1997; Rey, 1996; Weinger, 2001)

Make sure your car is in working order; Do you have gas in your vehicle???

Safety during home visitsDo advanced preparation•Program emergency contact numbers into

your cell phone (Scalera, 1995)

•Keep car locked (Newhill, 2006)

•Lock all valuables in the trunk- do not wait until you are in front of the house!! (Newhill, 2006)

Safety during home visitsDo advanced preparationDon’t leave anything within view inside

the car that might tempt someone to break in (Newhill, 2006)

Plan your route-minimize chances of getting lost

(Newhill, 2006)

Safety during home visitsDo advanced preparationDress appropriately – Professionally

attired, yet not intimidating (Avoid wearing expensive clothing)

Avoid wearing lots of jewelry or expensive jewelry

Don’t carry your credit cards or check book

Safety during home visitsDo advanced preparationCarry only your I.D., keys, and items

necessary to complete your assessment/intervention into the visit

Do not take your purse into the home

If people are loitering outside of the home and seem threatening, leave and return at another time

(Newhill, 2006; Weinger, 2001)

Safety during home visits

Advanced preparationPark where you can get out easily

Safety during home visitsPlan for connection with your agencyCharge your cell phone

Before you leave the office, sign out- make sure that others know where you are

Safety during home visitsConduct during visitClearly identify yourself

Note exits; Sit in the front room, next to the door

Walk confidently-look alert and aware

Safety during home visitsConduct during the visitDon’t interview people in the kitchen or

bedrooms

Don’t interview people in rooms where you can be boxed in

Don’t interview people in a room where you do not have ready access to an outside exit

Safety during home visits

Conduct during home visitKnow when to back off or take a time out

Stay aware of people in the vicinity

Terminate visit if things seem to be getting out of hand

Practice exercise: Safety during home visitsReferring to the information on home visit

safety, discuss with your small group how each guideline affects the way that you conduct your practice (i.e. which safety considerations do you currently have/ not have).

What other suggestions do you have for safety during home visits?

What changes could be made at your agency to improve worker safety during home visits?

What to do when violence has occurred (Weinger, 2001)

Admit that the violence occurred.

Crisis intervention- within 24-72 hoursVerbalizeNormalizeAlert worker to possible crisis reactionsTalk about coping strategies

Opportunity to work through feelings and reactions

What to do when violence has occurred (Weinger, 2001)

Remove the stigma of seeking support

Counseling for others:FamilyClients Co-workers

Organizational review of the incident

Practice exercise: What to do when a violent incident has occurredRead the The Case of C (Newhill, 1995)

Then respond to the questions on the handout regarding the possible feelings of the victim and possible workplace responses.

(From Weinger, 2001)

What to do when violence has occurred (Weinger, 2001)

Support for the victim from other staff members

Incident report writing

Practice exercise: Using incident report formsLook over the three incident report forms

that are provided. Choose the form that seems most

comfortable for you to use. Attempt to fill out the form, discussing a

serious client violent incident that occurred to you or another worker that you know

How could the form(s) be changed to more fully document the incidents?

(Forms are from OSHA and Newhill’s(2006) book)

Implications for social work practice

Implications for Social Work –Micro level planning and intervention1) Safety training for individual social

workers

2) Individual debriefing and support to social workers in the event that violence has occurred

3) Provide support to individuals when there is vicarious exposure to violence or fear of client violence

Need for systemic intervention

“ Rather than hunt for a few supposed “bad apples” in the barrel, we ought to examine the barrel itself, recognizing that violence is ultimately the product of social or organizational change and other factors that leave the workplace environment potentially volatile.”

(Denenburg & Braverman, 1999)

Mezzo level interventions

•Use of small group format to process when when incidents have occurred in an agency (i.e. Critical Incident Stress Debriefing (CISD)

•In social work education, use of field seminar to educate and support students when violence has occurred to one of the students or in a field agency

Macro level interventions

The agency’s response to a crisis may determine a more negative impact than the incident itself . “We individualize the impact of stress and trauma at our own peril.” (Adamson, 2006, p. 58)

Implications for Social Work- Macro level planning and interventionAgency safety policies and procedures

Plan for prevention/reduction of workplace violence

Zero tolerance for violence (Reeser & Wertkin, 2001)

Clear protocol for handling potentially violent and dangerous situations (Jayarante et al., 2004)

Formal process for reporting violence (Jayarante et al., 2004)

Consideration of temporary relief of duty or decreasing the workload and/or encouraging staff to seek medical attention, as necessary (Snow, 1994)

Agencies should offer safety training update at least annually.

Practice exercise: Awareness of Workplace Safety Plans

See OSHA and Newhill’s (2006) suggested workplace safety guidelines

Macro level interventions for social work education programs1) Infuse social work safety content across the

curriculum (minimally in practice classes and field seminar)

2) Field agency selection (Use only agencies that have written safety policies and procedures)

3) Safety training for field educators (see handout)

Macro level interventions for social work education programsWritten safety policies in social work education

programsa) Include a clear definition of client violence

(Faria & Kendra, 2007)

b) Obtain students’ informed consent regarding possible harmful situations in the field (Zakutansky & Sirles, 1993)

c) Formal reporting system- Incidents (including threats) must be reported to both the field educator and the field faculty (Ellison, 1996; Faria & Kendra, 2007; Horejsic & Garthwait, 1994; Ringstad, 2005)

d) Requirement to maintain record of client assaults to social work students (Mama, 2001; Ringstad, 1995).

Implications for Social Work -Macro level planning and intervention1) Support federal/state policies on social work

safety2) Risk management concerns- Get legal experts

to review social work program safety policies and procedures

Support for federal/state legislation that advocates for social work safetyFederal policy- None exists to date2007- U.S. Congressman Dennis Moore

proposed a bill that would award grants to states to provide safety measures such as:

GPS tracking devicesFacilities safety improvementsSafety training for social workers and

other helping professionalsPlease support:

Teri Zenner Social Work Safety Act

Support for federal/state legislation that advocates for social work safetyState policies on social work safety:Policies have been discussed in Michigan,

Washington, Kansas, Kentucky, West Virginia

(All of these are states where social workers have cruelly died and/or were severely injured)

Kansas-First in the nation to require safety training for social

workers- 4/8/10

The new law requires new social workers to take at least six hours of personal safety training as part of the 40 hours of continuing education required for all first-time license renewals. Most social workers will get the training soon after graduating with a social work degree.

Comment of Kansas Gov. Parkinson, upon signing social work training legislation“Social workers undertake one of the hardest, and

sometimes, one of the most dangerous jobs for our state. They take on this challenge because, ultimately, they want to help Kansans,” said Parkinson. “Unfortunately, it took the tragedy of Teri Zenner’s death to remind us about the importance of protecting the livelihood of our social workers. However, I am pleased to sign this legislation so they can continue the important work they are doing for Kansans with a better sense of safety and security.”

Comment of Teri’s husband, Matt Zenner, upon the signing:

• Teri’s husband, Matt Zenner, attended the signing of the legislation with Governor Parkinson.

• “I was told by investigators that, had Teri had some type of safety training, she likely would be here today practicing social work.  She is not here, but her colleagues are,” said Zenner.  “There are over 6,000 social workers licensed in Kansas.  Every year there are about 500 to 600 social work students graduating and becoming social workers.  Today, I feel hopeful and sure that they will have long careers helping others.”

Comment of Teri’s dad

•Teri Zenner’s father, Andy Mathis of Gardner, said more needs to be done to protect social workers. But he called today’s new law a critical step.

•“It means that Teri didn’t give her life in vain,” he said. “It’s been a long time coming.”

Risk Management

•“Risk management means prevention, early detection, and immediate intervention in injurious situations in the organization, in order to eliminate or minimize the risk of human harm or loss of resources.” (Nuehring & Houston, 1992, p. 58)

•Financial liabilities may exist when workers’ safety needs have not been adequately anticipated

Precedent for agencies/schools who may not adequately attempt to protect their social workers or students

•1995 Florida case – Nova Southeastern vs. Jill Gross, S.C. Case No. 94, 079

•23 yr old female doctoral student placed at a field agency that she knew to be in a dangerous neighborhood

•Given a manual which included safety precautions/ suggestions that she use a buddy system when leaving the building

•She was robbed and raped in the parking lot of the agency

Precedent for agencies/schools who may not adequately attempt to protect their social workers or students•Filed suit against the agency and the

school•Agency settled out of court for $900,000

Maintaining commitment to protection of social workersWe must avoid complacency.

“The moral is that preventing violence in the workplace is not about putting out fires or simply attending to the needs of the victims.

Ultimately, true prevention results from the ability to undergo an enduring change of outlook…”

(Denenbeurg & Braverman, 1999)

In Memory- Social workers who have given their lives in the course of duty

Teri Zenner, Kansas Killed 8/17/04 26 yrs. old, graduate student at University of

Kansas, died making a home visit to a mentally ill 17 yr. old

Boni Frederick, Henderson, Ky Killed 10/17/06

67 years oldKilled by a mother and her boyfriend, when she took a 9 month old child to visit his mother

In Memory- Social workers who have given their lives in the course of duty

Greg Gaul, Des Moines, Iowa 1962- 2004

42 yrs old Killed by a 16 yr. old client

Brenda Lee Yeager, Huntington, West Virginia 51 years old, Died 7/30/06 Killed while on a home visit

In Memory- Social workers who have given their lives in the course of duty

•Nancy Fitzgivens, Columbus, Ohio 53 years old (social worker for 2 years)

Killed during home visit

In Memory…• Donna Millette-Fridge, 36, New London, Connecticut. Stabbed by a

client while walking to work at a community mental health outreach program, Sept. 22, 1998.

• Steven Tielker, 41, Fort Wayne, Indiana. Shot by a client on probation for child molestation, April 28, 1997. Tielker, a Family and Children’s Services supervisor, counseled both victims and perpetrators of sexual abuse. The client, whom he was counseling under court order, also fatally shot a probation officer before taking his own life.

• Rebecca Binkowski, 25, Kalamazoo, Michigan. Stabbed in her car by a tenant at an apartment complex for persons with mental illness, where she worked as a resident manager, February 3, 1993. A graduate student at Western Michigan University, Binkowski was awarded her master’s degree in social work posthumously.

• Barbara Synnestvedt, 46, Whitmore Lake, Michigan. Beaten and strangled by a teenage inmate and sex offender at a juvenile detention center, April 25, 1993. Synnestvedt worked at the W.J. Maxey Training School.

• (From NASW News)

Contact Information:

Pam Criss, PhD, LCSWSoutheastern University1000 Longfellow BlvdLakeland, Florida 33801

863-667-5153pcriss@seuniversity.edu